Linking Up with Teledermatology

VOLUME: 11 PUBLICATION DATE: Mar 15 2003

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Profile: U.S. Army Using Teledermatology

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Linking Up with Teledermatology

Like the civilian population, the U.S. Army too suffers from the dermatologist shortage. That’s one reason why it’s using teledermatology in hospitals that have no dermatologist or where the demand is so intense that the dermatologist needs relief.
But, also like the civilian population, the Army is finding issues to deal with. Their lessons can be instructive for any program interested in teledermatology.
The first issue occurs when the hospital has no dermatologist. As a result, the hospital sends the patient to a civilian dermatologist. Currently, the Department of Defense pays for the cost of the visit; the hospital pays nothing, notes Dr. Hon Pak, who heads up the Army’s teledermatology effort.
To recapture the patients who would normally be sent to a civilian dermatologist, the referring hospital has to utilize more of its own resources. Moreover, there is no financial reimbursement to the referring hospitals. That means there’s no financial incentive for the hospital to send the patient out.
With the second issue, a primary care provider might request a dermatology consult. But if he requests a teledermatology consult, he has to follow a separate process and some of the follow-up work will return to him instead of being handled by the dermatologist. This disincents him from using the teledermatology pathway.
To resolve both issues, the Army will provide consult managers, which will cost the hospitals nothing. In addition, teledermatology will no longer be a separate consult process. All referred dermatology consults are screened and if deemed appropriate (using established clinical criteria), the patients are then scheduled for a teledermatology consult instead of giving the referring physician the option to use teledermatology or not. In essence, the consult process doesn’t change the referring primary care provider’s behavior or habits.
This year, the new model will be pushed out to the entire Great Plains Regional Medical Command, which represents one-third of the middle of the United States. Then, in the next year to year and a half, the plan could be pushed out to the entire Army and perhaps military, says Dr. Pak.

Store-and-Forward Gives High Accuracy

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Linking Up with Teledermatology

With proper application, both live interactive and store-and-forward technologies can provide teledermatology services. Though both seem equally effective, store-and-forward teledermatology is easier to set up and maintain than live interactive teledermatology. Recently, along with a medical student and another dermatologist, I conducted a study relating to inpatient dermatology consultations to compare the accuracy of store-and-forward diagnoses with live diagnoses. Some 48 patients were examined using store-and-forward technology followed by an in-person physical exam, as reported in an article in SkinMed (January 2003).
We found that 81% of the digitally derived diagnoses were consistent with the live derived diagnoses. Digital image diagnosis correlated with definitive diagnostic test results 76% of the time, while live compared to definitive diagnostic test results 73% of the time.
Notably, we found that with digital image diagnosis, we could more easily distinguish three-dimensional lesions, such as nevi, tags, keloids, and malignant growths than flat and more generalized lesions such as eczema, tinea, and drug rashes, as noted in the article.

Profile: Helping Rural Patients in Missouri

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Linking Up with Teledermatology

Based at University of Missouri Health Care, the Missouri Telehealth Network lays claim to 5,000 telehealth encounters – not counting radiology – since 1995. Dermatology represents the second biggest category of telehealth, after mental health, says Karen Edison, M.D., associate professor in the Department of Dermatology at the University of Missouri in Columbia. She is also medical director of the Missouri Telehealth Network. Some 2,000 of those visits are dermatology visits, she says, handled either by herself or another dermatologist based at the university.
Based in the center of the state in Columbia, the network serves a largely rural population. It reaches out 250 miles, covering from the Iowa border south to the boot heel of Missouri. On the other end of the line are rural health clinics, rural hospitals, and community health centers.
Using mainly live interactive technology, Dr. Edison sees about 15 patients every Tuesday afternoon, jumping to different locations around the state. Though usually accompanied by a presenter, sometimes the patient will be in a room alone.
At her busiest clinic, the General Leonard Wood Army Community Hospital, a dermatology physician assistant sits on the other end of the line with the patient. The PA, who works in a full-service clinic, can do procedures such as excisions and cryotherapy. He “is literally my hands,” she says.
For 90% of presenting complaints, teledermatology is an acceptable substitute for in-person care, she says. These patients wouldn’t get care otherwise. This isn’t substituting care but “delivering care where no care is available,” she says.

What About Online Consultations?

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Linking Up with Teledermatology

Besides live interactive and store-and-forward technologies, more physicians today communicate with patients via e-mail. Late last year, the eRisk Working Group for Healthcare, a consortium of medical societies and liability carriers, announced new guidelines for physician-patient e-mail.
“The legal rules, ethical guidelines and professional etiquette that govern and guide traditional communications between the healthcare provider and patient are equally applicable to email, Web sites, listserves and other electronic communications,” the document states. It notes that online communication raises security, authentication, confidentiality, and unauthorized access issues.
The group also provided guidelines for fee-based online consultations. These include the stipulation that online consults should occur only within the context of a previously established doctor-patient relationship, obtaining informed consent, and fee disclosure.
Recently, a study of RelayHealth Corporation’s “webVisit” system, which provides a structured way for doctors and patients to communicate via the Web, found reductions in healthcare spending, according to a press release. Notably, Blue Shield of California has said that it plans to reimburse physicians for webVisits.
Baltimore-based dermatologist Robert Weiss, M.D., of the Dermatology Associates/Maryland Laser Skin and Vein Institute notes that his Web site generates 40 to 50 e-mail messages per month. Potential patients, he says, may e-mail him images of, say, acne scars. His office takes a conservative approach, not offering treatment recommendations but only confirming that the office can handle the problem and recommending that the patient make an appointment.

Teledermatology — the use of technology to see patients at a distance — in some ways alters this relationship. No longer do patients visit an office and present complaints in person. Rather, a dermatologist looks at the patient via a telecommunications hook-up, perhaps with a clinician on the other end of the wire to assist with the “visit.”

Is this a brave new world that every dermatologist needs to understand and prepare for? Is this how you’ll see your patients in the future, especially given the shortage of medical dermatologists? Or will teledermatology remain a niche concept, bringing care to underserved populations but few others?
In this article, we’ll explore these questions, looking in some detail at the technology, its uses, benefits and drawbacks. First, though, a bit of history.

Nothing New
If you think teledermatology is a recent phenomenon, think again. The first two programs got cranking in the 1970s, according to Anne Burdick, M.D., M.P.H., professor of dermatology and director of the telemedicine program at the University of Miami.

One program linked the University of Miami with local prisons. The second linked a clinic at Boston’s Logan Airport with Massachusetts General Hospital.

In the 1990s, says Dr. Burdick, who is also Chair of the Telemedicine Task Force at the American Academy of Dermatology (AAD), teledermatology entered a second phase. Cheaper, off-the-shelf products like digital cameras made consults easier.

Today, the Telemedicine Information Exchange, Portland, OR, lists 67 U.S. telemedicine programs that include dermatology as one of its clinical areas. A survey from the Association of Telehealth Service Providers (ATSP), Portland, OR, found 22 dermatology programs and 703 consults for the first quarter of 2001 (see “Dermatology Programs”). This is said not to include data for all existing telemedicine programs, however.

Suited for Teledermatology
Dermatology stands as one of the prime applications for telemedicine. For instance, in fiscal year 2001, outside of radiology, dermatology represented the second most frequent application of telemedicine technology for programs funded by the federal government’s Office for the Advancement of Telehealth. The most common application was mental health.

Teledermatology is useful in two applications, according to Douglas Perednia, M.D., ATSP president. The first is where patients have no access to a dermatologist. The second is providing contact with dermatology subspecialties.

To date, teledermatology programs have focused on providing access to underserved communities, for instance in rural communities where few if any dermatologists may be available. “Telemedicine,” says the American Academy of Dermatology (AAD), “has the potential to substantially improve access to needed health care services and medical expertise, particularly in underserved areas.”

Telemedicine, Dr. Perednia notes, is happening almost entirely where the infrastructure takes care of payment — such as in a large university with salaried physicians. But it has failed to gain wide acceptance in private practice, mainly because of reimbursement issues, which we’ll cover in a moment.

Two Technologies
Clinicians deliver teledermatology using two major technologies: live interactive and store-and-forward. Dermatologists also communicate with patients using e-mail and the Web as well. (See “What About Online Consultations?”)

In live interactive, a dermatologist links to a clinic or primary care provider’s office. A “presenter,” who might be a physician, nurse practitioner or other clinician, waits on the other end of the line along with the patient. Using video cameras, the dermatologist views the patient’s skin condition, perhaps calling for a close-up image.

With store-and-forward technology, on the other hand, there’s no need for a presenter or patient to interact in real-time with the dermatologist (which provides major advantages, as we’ll soon see). Instead, text and images are stored and then forwarded to the dermatologist, who can view the material at his or her convenience. He or she can then return a diagnosis, recommendations for treatment, and so forth. In this way, store-and-forward allows freedom from both distance and time, notes Hon Pak, M.D., associate program director of the dermatology residency program at the U.S. Army’s San Antonio Uniform Services Health Education Consortium, San Antonio, TX.

High Accuracy
Dermatologists provide highly accurate feedback using either of these technologies. Between seeing a patient live over a live interactive hook-up, the concordance in diagnosis is about 80%, says Marc Goldyne, M.D., Ph.D., clinical professor of dermatology at the University of California San Francisco. That’s the same concordance rate as two dermatologists seeing a patient in the office. The rate increases to 90% if the dermatologists render a differential diagnosis instead of a single diagnosis.

What’s more, using store-and-forward technology instead of live interactive doesn’t make much difference. The concordance between one physician seeing a patient using live interactive versus store-and-forward still remains around 80%, notes Dr. Goldyne. (See “Store-and-Forward Gives High Accuracy.”)

Not for Everyone
Obviously, you can’t use teledermatology for all patients.
For instance, the technology hasn’t reached a point, says Dr. Pak, where a full body skin check is feasible, especially, say, for a patient who has a family history of melanoma.

But you might diagnose an obvious condition — psoriasis, for instance — because of its tendency to appear on the elbows and knees. Dr. Goldyne estimates that he could diagnose 60% to 70% of the patients he sees in his private practice by using store-and-forward teledermatology. Another potential prime application: monitoring and follow-up after a diagnosis.

Still, teledermatology is two-dimensional versus the in-person three-dimensional visit, says Raymond Dunn, M.D., professor of surgery at the University of Massachusetts Medical School and Chief of the Division of Plastic Surgery at University of Massachusetts Memorial Health Care, Worcester, MA. Dermatology presents more complex challenges than radiology, for instance, in the three-dimensional tactile nature of a lesion, says Baltimore-based dermatologist Robert Weiss, M.D., of the Dermatology Associates/Maryland Laser Skin and Vein Institute.

Better Technology
The technology itself imposes far fewer limits than it did years ago. For instance, as with almost all other electronic gear, prices have come down. These lower costs mean that almost any physician can afford the technology, says Joseph Kvedar, M.D., vice chair and associate professor of dermatology at Harvard Medical School, Boston, MA.

In a position statement adopted in February 2002, the AAD recommended that imaging and communications hardware used for telemedicine consults have at least 24-bit color and an analog display resolution and camera output of 450 lines. For computer screens, it recommended a minimum of 640 x 480 pixel resolution with 24-bit color on a monitor of 0.28 dot pitch. It also recommended a digital camera with a minimum one megapixel resolution with close-up/macro capability. Dr. Pak ups that to 1024 x 768 for store-and-forward.

You’ll also need special software to use with store-and-forward applications. For instance, you want to ensure that a specific image is correctly linked to a specific patient, says Dr. Burdick. This argues against simply using plain vanilla e-mail to zip images around.

Hurdles to Overcome
Despite all the whiz-bang technology, teledermatology has a long way to go before it’s a regular part of most dermatology practices. Among the barriers are problems with scheduling and reimbursement. State licensure also presents an issue.

Live interactive carries major scheduling challenges in that typically three people have to show up at the right place at the right time — the patient, the presenter and the dermatologist.

“The biggest problem with it,” says Dr. Goldyne, “is logistics.” “Incredibly inefficient” is the verdict from Jack Resneck, Jr., M.D., assistant professor of dermatology at the University of California San Francisco.

One idea behind telemedicine, says Dr. Goldyne, is that it would shorten the waiting time for a dermatology appointment. But in his practice, he’s found that “because you devote a specific physical amount of time to it, eventually you get a back-up” just as you do in your office.

Unfortunately, that means patients still might have to wait 6 to 8 weeks for a live interactive consult. Given the dermatologist shortage, “you’re not going to get too many dermatologists to sit there and do these consultations,” says Dr. Pak.

To a certain extent, store-and-forward technology eliminates these concerns. Because the dermatologist is reviewing text and images at his or her convenience, there’s no need to bring together a presenter, patient, and dermatologist all at one time, alleviating the logistics problem.

But it’s not the panacea one might expect. Frequently in smaller clinics, the person taking the image may obtain the wrong one, notes Dr. Perednia. For instance, he or she might provide a close-up digital photo when distribution might be far more important. In person, a physician can simply look at the distribution, the close-up, or both without any additional hassle.

The Pay Problem
Besides scheduling, teledermatologists face problems in making teledermatology financially workable. In 1997, Medicare received approval to reimburse for live interactive telemedicine consults, with some restrictions.

Since then, those regulations have been eased. For instance, restrictions that meant that only a physician could be a presenter were expanded to include certain nurses, says Dr. Burdick. Currently, reimbursement is only for non-metropolitan areas.

But even with the relaxing of restrictions, the logistics still give pause. For instance, Brian Zelickson, M.D., of Skin Specialists in Minneapolis, MN, tried live interactive with rural physicians in Minnesota.

But he estimates he can see five patients in the time it takes him to perform one teledermatology consult. Economically, such a system “isn’t very viable,” he says, and he’s waiting for reimbursement for store-and-forward instead.

As for store-and-forward, the picture is even worse. Medicare has never paid for store-and-forward teledermatology, even though dermatology is “eminently suitable” for store-and-forward systems, says Dr. Burdick. Because store-and-forward isn’t reimbursed by Medicare but represents the most efficient teledermatology method, “it’s limiting the expansion of this kind of service,” she says.

In setting up systems to handle such matters as scheduling referrals and generating reports, and in bumping other patients to see teledermatology patients, the dermatologist gains no advantage, says Dr. Perednia. In fact, he argues, a telemedicine consult then becomes a slightly more expensive transaction than a live one.

“In the interest of making dermatologic expertise available to all patients, reimbursement for telemedicine consultations by public (Medicare and Medicaid) and private third party payers is supported at the same level as an office consultation,” notes the AAD in its February 2002 position statement on telemedicine.

“If they had reasonable reimbursement, this thing would go,” states Dr. Zelickson.

At least one payor reimburses for store-and-forward teledermatology. California’s Blue Cross Healthy Families program, says Dr. Goldyne, pays for store-and-forward consults. He also has a small percentage of private-pay patients, whom he bills $45 per store-and-forward consult.

And note that costs are in some ways less than with a traditional setup. For instance, Dr. Burdick’s faculty practice charges her for office space and staff. But with a telemedicine, you have “no real overhead,” she explains.

License Question
Besides these concerns, teledermatologists struggle with state licensure issues. Does a dermatologist go beyond the scope of his state license if he sees, via teledermatology, a patient whose image is being beamed from another state?

Each dermatologist needs to be licensed in the state where the patient is located, notes Dr. Burdick. Each state is responsible for the health and welfare of its citizens, so it’s unlikely that a national licensure system will appear anytime soon, she says.

Minnesota allows physicians to apply for a telemedicine license, says Dr. Zelickson. Thus a physician residing elsewhere could via teledermatology see a patient who lives in Minnesota.

Another issue involves whether malpractice insurance will cover a teledermatologist. Dermatologists would want to notify their malpractice carrier about doing teledermatology, Dr. Burdick notes.

No Workforce Solution
Unfortunately, teledermatology isn’t likely to solve the workforce challenges confront-ing dermatology. It will be an “important component” of dealing with it, says Dr. Kvedar, because it will be able to “change some of the geographic maldistribution of physicians.”

But, he notes, that maldistribution isn’t going to disappear because of dermatologists’ preference to live in certain areas of the country.
Also, if you’re up at night worrying about teledermatologist stealing your patients, rest easy. When Dr. Goldyne works with remote sites, most of the time one dermatologist might work in the area but doesn’t see Medicare or Medicaid patients. Another possibility: a local dermatologist who does mainly cosmetic dermatology, he notes.

Teledermatology, argues Dr. Pak, isn’t about whether you send your mother, for instance, to a dermatologist or a teledermatologist tomorrow. Rather, it’s about whether you send her to a teledermatologist tomorrow or have her wait 6 months to see a dermatologist in person.

Future Prospects
Given the logistics issues, reimbursement concerns, and other problems, you’re not going to be doing teledermatology full time anytime soon. Dr. Goldyne says he could see a group of dermatologists in perhaps 10 or 15 years doing teledermatology full-time.

But, he thinks that the time isn’t too far off when the government and other agencies will see that telemedicine “does allow given specialties to provide quality care at a distance.”

Similarly, teledermatology will form a part of future healthcare delivery, predicts Dr. Pak. He suggests that the adoption rate will increase a great deal once reimbursement issues are resolved.

The present challenge, says Dr. Kvedar, involves workflow issues, developing a consistent economic model for teledermatology, and educating providers and patients about the relative value and advantage of the opportunity to access centers of excellence.

Think, he says, not about such issues as what camera or computer to buy, but about what clinical need you can meet that’s geographically different from where you are. And because teledermatology represents a different way of delivering healthcare, you’ll need passion and commitment for the long haul.

Part of Your Future?
Even though electronics intervenes between you and the patient, teledermatology still fundamentally involves a patient-physician interaction. Used appropriately and with adequate financial support, it could become a portion of your practice in the not-so-distant future.

(Next month, read about the impact of HIPAA on teledermatology — plus, information about new reimbursement models.)

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